Criteria for Excellence | Chapter 11: Key terms and concepts​​​​

Accountable Care Organization (ACO): An ACO is a group of physicians, hospitals, and other health care providers that come together voluntarily to give coordinated, high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

Accreditation Council for Graduate Medical Education (ACGME)​: The ACGME is a private, nonprofit organization that reviews and accredits U.S. graduate medical education (GME)—residency and fellowship—programs and the institutions that sponsor them.

American Academy of Family Physicians (AAFP): The AAFP is the national association of family physicians, with more than 129,000 members. The AAFP was founded in 1947 to promote and maintain high-quality standards for family physicians who are providing continuing comprehensive health care to the public.

American Association of Colleges of Osteopathic Medicine (AACOM)​: The AACOM provides leadership for the osteopathic medical education community by promoting excellence in medical education, research, and service, and by fostering innovation and quality across the continuum of osteopathic medical education to improve the health of the American public.

American Board of Family Medicine (ABFM)​: The ABFM is the professional board for family medicine and maintains additional training requirements for programs to meet for graduates to be eligible to become board certified in family medicine.

American College of Osteopathic Family Physicians (ACOFP)​: The ACOFP is a professional medical association that represents more than 20,000 practicing osteopathic family physicians, residents, and students throughout the United States. The ACOFP works to promote excellence in osteopathic family medicine through quality education, visionary leadership, and responsible advocacy.

American Osteopathic Association (AOA)​: The AOA serves as the professional family for more than 110,000 osteopathic physicians (DOs) and osteopathic medical students. It promotes public health and encourages scientific research. In addition to serving as the primary certifying body for DOs, the AOA is the accrediting agency for all osteopathic medical schools through the Commission on Osteopathic College Accreditation (COCA)​ and has federal authority to accredit hospitals and other health care facilities.

American Osteopathic Board of Family Physicians (AOBFP)​: AOBFP purpose is to determine the qualifications required of osteopathic family physicians seeking initial and continued certification awarded by the American Osteopathic Association (AOA) in the field of family medicine and any other field that may be assigned; develop the methods of examination to assess those family physicians; administer and evaluate examinations to assess competency and excellence in those fields; and issue the appropriate certification upon the approval of the AOA. The AOBFP is the osteopathic counterpart to the allopathic American Board of Family Medicine (ABFM).

Association of American Medical Colleges (AAMC):​ The AAMC is a nonprofit association representing all accredited medical schools in the U.S. and Canada, nearly 400 major teaching hospitals and health systems (including 51 U.S. Department of Veterans Affairs [VA] medical centers), and nearly 90 academic and scientific societies.

Association of Departments of Family Medicine (ADFM)​: The ADFM is the organization of departments of family medicine and is devoted to transforming care, education, and research to promote health equity and improve the health of the nation.

Association of Family Medicine Residency Directors (AFMRD)​: The AFMRD is a nonprofit organization that exists to inspire and empower family medicine residency program directors to achieve excellence in family medicine residency training.

Clinical Competency Committee (CCC): CCC is the ACGME “required body comprising three or more members of the active teaching faculty who is advisory to the program director and reviews the progress of all residents in the program.”

Community-Oriented Primary Care (COPC): The COPC model strives to efficiently distribute, organize, and systematize existing health care resources. In addition to promoting healthy lifestyles within the community, the COPC model enables the health care team and the community to cooperate in identifying and prioritizing health issues. Together, they develop and implement prevention and treatment plans for those priority areas.

Core faculty: There are two core faculty definitions for family medicine. One is the Common Program Requirements definition (see ACGME Glossary of Terms, July 2013​); all specialty residencies in the United States must comply). A second, expanded one defines core faculty for family medicine residencies (addressing the issues that administration/teaching of family medicine is more complex than most specialties given its scope) as follows:

• ACGME Review Committee Family Medicine Core Faculty Definition: In addition to the program director, there must be one additional core faculty for each six resident full-time equivalents (FTEs) (2-2-2). For a 24-FTE (8- 8-8) resident program, there must be four FTEs of core faculty. For a 30- FTE (10-10-10) resident program, there must be five FTEs of core faculty. For a 36-FTE resident program, six core faculty are required. These positions cannot be shared, and each must dedicate at least 24 hours per week (or 1,200 hours per year, which is 60% of time based on a 40-hour workweek) to nondirect patient care activities supporting the residency (e.g., educational activities, supervision, scholarly work, advising, residency administration).

Council of Academic Family Medicine (CAFM)​: CAFM consists of the four academic family medicine organizations: The Association of Departments of Family Medicine (ADFM), the Association of Family Medicine Residency Directors (AFMRD), the North American Primary Care Research Group (NAPCRG), and the Society of Teachers of Family Medicine (STFM). Founded in 2008, CAFM coordinates activities where there is overlap and acts upon strategic initiatives that support academic family medicine and the discipline.

Entrustable Professional Activities (EPAs)​: Olle ten Cate, PhD, defines EPAs as units of professional practice, defined as tasks or responsibilities to be entrusted to the unsupervised execution by a trainee once he or she has attained enough specific competence. EPAs are independently executable, observable, and measurable in their process and outcome, and therefore, suitable for entrustment decisions.

Family medicine center (FMC): The former term for the physical location of the family medicine clinic or practice. Now called family medicine practice (FMP) site.

Family medicine practice (FMP): The place(s) where patients receive their care, which can often be beyond the walls of the family medicine center (FMC)/family medicine practice site (FMP site).

Family medicine practice site (FMP site): The physical location of the family medicine clinic or practice, formerly called the Family Medicine Center (FMC).

Graduate medical education (GME) finances: See a list of GME finance-related terms here.

Health and Medicine Division (HMD)​: The HMD – formerly the Institute of Medicine (IOM) – is a division of the National Academies of Sciences, Engineering, and Medicine. The academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions related to science, technology, and medicine.

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): A ground- breaking revision of the Medicare payment system that moves away from the traditional fee-for-service system to one based upon value-based care. This law repeals the flawed Medicare sustainable growth rate (SGR) formula that calculated payment cuts for physicians. MACRA establishes an alternative set of predictable annual baseline payment updates and two payment tracks: the alternative payment model (APM) track and the merit-based incentive payment system (MIPS) track.

Milestones: A milestone is a significant point in educational development. For accreditation purposes, the Milestones are competency-based developmental outcomes (e.g., knowledge, skills, attitudes, performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties.

National Board of Osteopathic Medical Examiners (NBOME)​: The NBOME is an independent, nongovernmental, not-for-profit organization with a mission to protect the public by providing the means to assess competencies for osteopathic medicine and related health care professions.

National Institute for Program Director Development (NIPDD)​: The NIPDD is a nationally recognized fellowship program that uses a one-of-a-kind adult learning model to enhance knowledge, attitudes, and skills to groom effective residency program directors.

Next Accreditation System (NAS)​: The NAS is the ACGME accreditation system, which focuses on educational outcomes and a process of continuous improvement. It introduced new terms and processes related to setting outcome measures and assessments, including the Milestones, Clinical Competency Committee (CCC), and Program Evaluation Committee (PEC).

North American Primary Care Research Group (NAPCRG)​: NAPCRG is an interdisciplinary, multi-national volunteer association committed to nurturing primary care researchers to improve health and health care for patients, families, and communities.

Osteopathic Recognition/Osteopathic Recognition Track​: Osteopathic Recognition is conferred upon any ACGME-accredited graduate medical education (GME) program providing requisite training in the Osteopathic Principles and Practice (OPP). Programs may be deemed to have Osteopathic Recognition after appropriate application, evaluation, and review of the standards outlined below. Programs receiving Osteopathic Recognition may designate the entire program as osteopathic-focused or designate a portion of the program as an osteopathic-focused track.

Process Improvement Methodologies:​ Process improvement is defined as a systematic approach to closing process or system performance gaps through streamlining and cycle time reduction, and identifying and eliminating causes of below-specifications quality, process variation, and non–value-adding activities. A variety of methodologies are available for process improvement, including Six Sigma, lean management, Lean Six Sigma, agile management, Total Quality Management, and Kaizen, among others.

Program Evaluation Committee (PEC): Appointed by the program director, the PEC comprises at least two program faculty members and should include at least one resident. The PEC must meet at least annually. It is responsible for addressing areas of noncompliance with minimum Accreditation Council for Graduate Medical Education (ACGME) standards, and it may improve the program to go beyond minimum standards.

Quadruple Aim​: A framework that uses the Triple Aim as its core and adds a fourth dimension: improving work life of health care providers, including clinicians and staff. See Triple Aim.

Quality Improvement (QI): The Health Resources and Services Administration (HRSA) defines QI as a series of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. The Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering and Medicine defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations.

Review Committee for Family Medicine (RC-FM)​: The RC-FM is the ACGME committee that is responsible for reviewing family medicine residency programs to determine compliance with requirements.

Single GME Accreditation System​: The single accreditation system allows graduates of allopathic and osteopathic medical schools to complete their residency and/or fellowship education in ACGME-accredited programs and demonstrate achievement of common Milestones and competencies. It also allows for incorporation of training of osteopathic principles through the Osteopathic Recognition Requirements for allopathic programs and residents.

Society of Teachers of Family Medicine (STFM)​: STFM exists to advance family medicine to improve health through a community of teachers and scholars, including medical school professors, preceptors, residency program faculty, residency program directors, and others involved in family medicine education.

Triple Aim​: The Triple Aim is a framework developed by the Institute of Healthcare Improvement (IHI) that describes an approach to optimizing health system performance which involves new designs to simultaneously pursue three dimensions (ie, the "Triple Aim"): (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing the per capital cost of health care. See Quadruple Aim.

United States Medical Licensing Examination (USMLE): The USMLE program supports medical licensing authorities in the United States through its leadership in the development, delivery, and continual improvement of high-quality assessments across the continuum of physicians’ preparation for practice.

Critical Access Hospital (CAH)​: A CAH is a hospital certified under a set of Medicare Conditions of Participation (CoP), which are paid differently than an IPPS hospital (see below). The CAH program is designed to financially support rural hospitals that otherwise would not be viable if paid under the standard IPPS method. Some of the requirements for CAH certification include having no more than 25 inpatient beds; maintaining an annual average length of stay
of no more than 96 hours for acute inpatient care; offering 24-hour, 7-day-a-week emergency care; and being in a rural area, at least 35 miles drive from any other hospital or CAH (fewer in some circumstances). Since a CAH is NOT paid under the DRG system by Medicare it is not eligible for traditional Medicare GME payments (DGME and IME). A CAH however may claim
residency training costs and can get reimbursed some of this via Medicare billings. This is roughly the math equivalent of DGME.

Disproportionate Share Hospital (DSH)​: A DSH serves a significantly disproportionate number of low-income patients and receives payments from the Centers for Medicare & Medicaid Services (CMS) to cover the costs of providing care to uninsured patients. When a residency practice provides a large amount of indigent care this may push the hospital into qualifying for
DSH payments they otherwise would not receive.

Graduate medical education (GME) funding: Residency training is funded primarily through the Centers for Medicare & Medicaid Services (CMS) with payments to hospitals that participate in residency training. Medicare GME comprises two parts: direct and indirect medical education funding.

• Direct graduate medical education (DGME) funding​: DGME is designed to
  reimburse hospitals to compensate for Medicare’s share (based on bed days) of the direct costs of training residents (including salary, benefits, liability costs, etc.). DGME usually represents about one-third of the amount paid to hospitals for GME.
• Indirect medical education (IME) funding: IME is designed to cover the “nondirect” costs of residency education (including the cost of additional tests, longer lengths of stay, etc.) that have been attributed to the presence of residents in a hospital. In most residencies’ financial plans, IME does not represent excess costs of care. Instead, it functionally makes up for the “non-Medicare share” in the DGME calculation. IME is typically two-thirds of the total GME Medicare payments to a hospital.

Hospital cap (cap): Established inpatient prospective payment system (IPPS) teaching hospitals are subject to a cap on the number of residency positions that can be funded by the Medicare graduate medical education (GME) program. With rare exceptions, these caps are fixed after five years once a new residency is established that involves a new IPPS teaching hospital.

Inpatient Prospective Payment System (IPPS)​: Most U.S. hospitals are IPPS hospitals and receive Medicare payments for patient care via the diagnosis- related group (DRG) system.

Medicaid GME: States can elect to fund graduate medical education (GME) through Medicaid and are eligible to receive federal matching funds if they choose to invest in this model.

Per resident amount (PRA)​: The PRA is a key determinant of Direct Graduate Medical Education (DGME) funding, and, once established, is a permanent dollar amount (with annual inflation adjustment) for the hospital in perpetuity. The PRA times “Medicare’s share of bed days” equals the DGME payment per eligible FTE resident.

Rural vs. urban hospitals: For purposes of graduate medical education (GME) funding, the Centers for Medicare & Medicaid Services (CMS) designates hospitals as “rural” or “not rural” based on a set of criteria found on the CMS website​. Hospitals located outside metropolitan CBSAs are generally classified as rural. Rural hospitals have some GME flexibility in being able to add new specialty residencies and restart their cap-building process. Other hospitals
cannot do this and must build whatever single or multi-specialty GME system they desire within five years at which time the hospital is capped.

Sole community hospital (SCH): SCH is designated by the Centers for Medicare & Medicaid Services (CMS) as meeting certain criteria based on location, size, or distance. An SCH receives payment for its operating costs based on the federal inpatient prospective payment system (IPPS) rate or on its hospital-specific rate, whichever results in the greatest aggregate payment. Although all SCHs can receive direct graduate medical education (DGME) payment, only those that receive the federal rate for inpatient services can receive indirect medical education (IME) payment. SCHs that are paid their hospital-specific rate are not eligible for IME payments except for IME calculated for Medicare Advantage care.